The nurse has completed client teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse determines that the client best understands the information given if the client states to record the daily:
A. Pulse and respiratory rate
B. Intake, output, and weight
C. BUN and creatinine levels
D. Activity log
Correct Answer: B. Intake, output, and weight
The client on hemodialysis should monitor fluid status between hemodialysis treatments by recording intake and output and measuring weight daily. Ideally, the hemodialysis client should not gain more than 0.5 kg of weight per day. Measure all sources of I&O. Weigh routinely. Aids in evaluating fluid status, especially when compared with weight. Weight gain between treatments should not exceed 0.5 kg/day.
Option A: The nurse should monitor BP and pulse. Hypertension and tachycardia between hemodialysis runs may result from fluid overload and/or HF. Note presence of peripheral or sacral edema, respiratory rales, dyspnea, orthopnea, distended neck veins, ECG changes indicative of ventricular hypertrophy.
Option C: The nurse should monitor serum sodium levels. Restrict sodium intake as indicated. High sodium levels are associated with fluid overload, edema, hypertension, and cardiac complications.
Option D: The nurse should note changes in mentation. Fluid overload or hypervolemia may potentiate cerebral edema (disequilibrium syndrome). Restrict PO/IV fluid intake as indicated, spacing allowed fluids throughout a 24-hr period.
No comments:
Post a Comment